**6. The limitations of carotid endarterectomy**

This NASCE, ACAS and ESCT trial as well as the spread of carotid endarterectomy worldwide unveiled the problems and limitations inherent to the procedure. It became clear that the coexistence of cardiac co-morbidity is a powerful predictor of mortality and that myocardial infarction can be the most dreaded complication, even more than stroke. This was evident, despite the fact that patients with myocardial infarction in the prior six months, congestive heart failure and patients scheduled for coronary revascularization were excluded from the large CEA trials.[6] Other limitations of the procedure were more located to the local envi‐ ronment in the neck as prior endarterectomy, prior neck dissection or radiation, cranial nerve palsies and inaccessible high/low carotid bifurcations. The presence of contra-lateral carotid occlusion also posed a problem during cross clamping that increased the risk of CEA.
